Requesting a Medication Authorization · blueshieldca.com Blue Shield of California 50 Beale...
Transcript of Requesting a Medication Authorization · blueshieldca.com Blue Shield of California 50 Beale...
Requesting a Medication Authorization – updated June 2019.
Below are the steps (plus helpful information) for requesting a medication authorization in
AuthAccel. Note the difference between a medication and a pharmacy request:
• MEDICATION authorization request is for medication administered in a doctor’s office, infusion
center, home health agency, or other outpatient clinical setting.
• PHARMACY request is for medication that is prescribed to and self-administered by the patient.
Guidelines for working in AuthAccel
• Authorization requests must be completed in one session – work will not be saved if
the system is exited prior to submitting the request.
• AuthAccel times out after 30 minutes of inactivity and will not save unsubmitted
entries.
• Google Chrome is the preferred browser for AuthAccel. (Other browsers will work but
Chrome provides more consistent performance.)
• If Chrome has “autofill forms” functionality turned on, you may see previous entries
present as drop-down options in some fields. You can turn “autofill forms” off or on by
going to Settings > Advanced > Passwords and forms > Autofill settings.
• Use AuthAccel navigation when working in the system.
• Mandatory fields in AuthAccel are indicated with an asterisk (*) and must be
completed to submit a request.
• Drop-down lists include search-as-you-type functionality. Click in the drop-down text
box and begin typing to display a list of options that best match the entry.
• For convenience, a link is provided from AuthAccel to Blue Shield’s Clinical Policies
and Guidelines.
Determine if an Authorization is Required and Identify Needed Documentation
1. Log in to Provider Connection.
2. Click the Medical Authorization link located under the blue Authorizations box on the
home page.
• The page is also accessible from the Authorizations section.
3. Scroll to Step 1: Check if authorization is required.
4. Click the *radio button next to the appropriate line of business: either Commercial or
Federal Employee Plan (FEP).
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5. Enter a *CPT or HCPCS code in the field provided.
6. Enter at least one *diagnosis code and click Check.
7. Results will display directly below the Check button.
8. If authorization is required from Blue Shield, a paragraph will display that provides
information about required medical documentation. Click the here link to access
these documents.
9. One or more Required Medical Documentation links will display.
10. Click each link and scroll to the Patient Clinical Information section for an itemized list
of documentation that must be submitted with the authorization.
• The form can be printed. It does not need to be attached to the authorization if
you are submitting via AuthAccel.
Access AuthAccel
11. Scroll to Step 2: Request medical authorization.
12. Select the Tax ID Number from the drop-down list under which you will submit or view
authorizations.
13. Click Go.
14. AuthAccel opens in a new window.
• When submitting or viewing additional authorizations under a different Tax ID
Number, close AuthAccel, come back to this page, and select the new Tax ID.
Define Request
15. Enter the member’s First Name, Last Name, Date of Birth (mm-dd-yyyy) and Member
ID with or without the alpha prefix.
16. Click Search. The Member Search Results window displays.
• If the Member Search Results window displays “Member not eligible,” check that
all entries are correct.
▪ If the member name is spelled incorrectly, a number is entered incorrectly,
or the date of birth (DOB) is entered in the wrong format, the system will
not be able to locate the member.
▪ If the DOB is not entered in the mm-dd-yyyy format, it will default to
today’s date.
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• More than one listing for the same member may display if that member has
experienced periods of ineligibility with Blue Shield. Review the “Status” column
and select the “Eligible” option. It should be at the top of the table.
• To print a PDF of the Member Search Results window, click the Print button
located in the lower right corner.
17. Click Select in the left column to select the member.
• To view the member’s eligibility history, click the green Member Eligible button at
the top of the screen. To close the Patient Eligibility History window, click Cancel
or the X in the upper right corner.
18. Select Authorization Urgency. “Standard” is the default.
• When “Expedited” is selected, an Expedited Review attestation presents. If after
reviewing this attestation, “Expedited” is not the appropriate selection, click the
Standard radio button.
19. Select the correct provider from the *Requesting Provider drop-down list. The list
contains the Provider ID Number (PIN), the provider and/or facility name (if
applicable), and address.
• Remember, drop-down lists include search-as-you-type functionality. If multiple
Provider ID Numbers (PINs) present, click in the drop-down list and type the
desired PIN to narrow the options.
• Multiple listings of the same provider can present if they practice at several
locations. Select the listing that matches the address for which you are
submitting the authorization.
20. The Specialty and Provider Status fields are populated based on the requesting
provider selected from the *Requesting Provider drop-down list and cannot be edited.
21. The following demographic fields are populated based on the requesting provider
selected from the *Requesting Provider drop-down list:
• *First and *Last Name
• *Address1, Address2, *City, *State and *Zip
• *Phone Number and *Fax Number
▪ Note, there may be a slight time lag for fields to populate.
22. Review the demographic information for completeness and accuracy. Make
corrections or additions if necessary.
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23. Select the Yes or No radio button for Requesting Provider Same as Servicing Provider.
“No” is the default.
• Note, if the requesting provider is different from the servicing provider,
information about the servicing provider must be entered in the Servicing and
Facility Providers section for the authorization to submit.
24. Select Medication from the Request Type drop-down list.
25. Select a service location from the *Place of Service drop-down list.
26. If the member has a Cal-MediConnect or PPO/POS (point of service) plan, the Claims
Payment Type field will present. Use the drop-down list to indicate which plan will be
primary.
• If no selection is made, members with a Cal-MediConnect plan will default to
Medicare for claims payment, and members with a PPO/POS plan will default to
HMO.
Add Servicing and/or Facility Provider
27. If No is selected in the Requesting Provider Same as Service Provider field, information
about the servicing provider must be entered in the Servicing and Facility Provider
Information section. This section is also where to add information about a facility.
TO ADD A SERVICING PROVIDER:
28. Click the Add Servicing/Facility Provider button.
29. The Search for Servicing Provider or Facility window displays.
30. Enter the servicing provider’s NPI in the appropriate field.
31. Click the Par Yes or No buttons to indicate if the servicing provider is in the Blue Shield
network. “Yes” is the default.
32. Select “Servicing Provider” from the *Type drop-down list.
33. Click Search. The search results display.
• The most effective way to search for a servicing provider is by NPI. If you do not
have the NPI number, search by entering the provider’s State and partial or full
First Name and Last Name.
• Click the Show Additional Search Fields button to refine your search by adding
criteria such as city, zip code, or provider specialty. To collapse additional field
options, click the Hide Additional Search Fields button.
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• Click the Clear button to remove search criteria from primary and additional
search fields.
34. Click Select in the left column to select the correct servicing provider.
35. The Servicing/Facility Provider Fax Number window presents. Enter the servicing
provider’s *Fax Number in the field and click Save.
36. The servicing provider information displays in the Servicing and Facility Provider
Information section.
TO ADD A FACILITY:
37. Click the Add Servicing/Facility Provider button.
38. The Search for Servicing Provider or Facility window displays.
39. Enter the facility’s NPI in the appropriate field.
40. Enter the State (e.g., CA).
41. Click the Par Yes or No buttons to indicate the type of provider. “Yes” is the default.
42. Select “Facility” from the *Type drop-down list.
43. Click Search. The search results display.
• The most effective way to search for a facility is by NPI. If you do not have the
NPI number, search by entering the Organization name in the appropriate fields.
• When searching for a facility, it is better to enter an organization name that is
more inclusive (e.g., St Maximus vs. St Maximus Medical Center). Being too
precise can result in a “No providers found” message
• Click the Show Additional Search Fields button to refine your search by adding
criteria such as city, zip code, or provider specialty. To collapse additional field
options, click the Hide Additional Search Fields button.
• Click the Clear button to remove search criteria from primary and additional
search fields.
44. Click Select in the left column to select the correct facility.
45. The Servicing/Facility Provider Fax Number window presents. Enter the facility’s *Fax
Number in the field and click Save.
46. The servicing provider information displays in the Servicing and Facility Provider
Information section.
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TO ADD AN UNKNOWN PROVIDER:
47. If the search results do not return the desired servicing provider and/or facility, close
the search window and click the Add Unknown Provider button. The Enter Servicing
Provider or Facility Information window displays.
▪ Complete the fields with what you know. Note, *Fax is a required field.
▪ Select the *Type from the drop-down list.
▪ Click Save. The information displays in the Servicing and Facility Provider
Information section.
48. To remove a servicing provider or facility that you have entered, click the Remove
button in the Action column.
*Add Diagnosis
49. Under the *Diagnosis section, click the Add Primary Diagnosis button.
50. The ICD Search window displays. Searches can be conducted by full or partial ICD-10
codes (first three digits) or by principle diagnosis description.
• Note, more complete search criteria will return more targeted results because
searches are inclusive. For example, typing in “D63” will return all ICD-10 codes
that include the “D63” sequence. Similarly, “anemia” will return a list of all
diagnoses that include that term anywhere in the description.
51. Click Search. The search results display.
52. Click Select in the left column to select the appropriate diagnosis from the options
provided.
53. Note, the diagnosis information displays in the *Diagnosis section. If necessary, click the
Add Diagnosis button and follow the same process to add additional diagnoses.
• Do not use the Add Primary Diagnosis button to add additional diagnoses as it
will overwrite your initial entry.
54. To remove a diagnosis that you have entered, click the Remove button in the Action
column.
*Add Procedure
55. Under the Procedure section, click the Add Procedure button.
56. The CPT/HCPCS Search window displays. Enter a complete or partial CPT/HCPCS code
or procedure description. Remember, more complete search criteria will return more
targeted results because searches are inclusive.
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57. Click Search. The search results display.
58. Click Select in the left column to select the appropriate procedure from the options
provided.
59. The CPT/HCPCS Information window displays. Populate as many fields as possible with
what is known about the procedure. Here is an example:
CPT/HCPCS Information window
Fields Description / Instructions Example
CPT/HCPCS Code Not editable J0885
Procedure
Description Not editable
INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS
Short Description
A short description is necessary if
using unlisted or miscellaneous
(generic) codes.
Leave blank if not applicable.
*Quantity
This is a mandatory field. Enter the
amount or number that best
matches the request.
30
*Units
This is a mandatory field. Select the
description that best aligns with
the quantity. Units are typically the
most appropriate selection for
medication requests.
Units
Frequency
Mandatory field. Select the
frequency that best aligns with the
unit selection. There are multiple
frequency options. Click in the
drop-down text box and begin
typing. The system will display
options based on the first letters or
numbers of your entry.
Weekly
Requested Total
Duration of Therapy
Select the therapy duration that
best aligns with the quantity, units,
frequency. Select Other from the
Requested Total Duration of
Therapy drop-down list if the
preferred duration is not a menu
option. A field will present where a
12 weeks
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CPT/HCPCS Information window
Fields Description / Instructions Example
short description of the desired
duration can be entered.
Start and End Dates
The start date defaults to today’s
date, and the end date defaults
to three months after today. Use
the defaults or enter the dates that
best align with the requested total
duration selection.
09-30-2016
10-01-2016
Modifier 1 and 2
Description
Modifiers are included when there
is a need to specify specific areas
on the body like right or left leg. To
access a Modifier Search window,
click the magnifying glass.
Leave blank if not applicable.
60. Click Submit.
61. Note, the procedure information displays in the *Procedure section. Repeat the
process to add additional procedures.
62. To remove a procedure that you have entered, click the Remove button in the Action
column.
Add Known Allergies (This is not a mandatory section.)
63. To add allergy information, click the Add Allergies button.
• Typically, allergy information is added when it influences the procedure and/or
diagnosis in some way. Note that if other providers with logins connected to the
same Tax ID Number have entered allergy information about this specific
member, it is populated in the Known Allergies section.
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64. The Allergies window displays. Populate as many fields as possible with what is known
about the member’s allergies. Here is an example:
Allergies window
Fields Description / Instructions Example
*Allergy Type This is a mandatory field. Medication
NDC
Click the magnifying glass. Enter a full
or partial NDC or medication name
and click Search. Click Select in the
left column to select the appropriate
drug from the options provided and
populate the field.
68016034314
Medication Field is automatically populated by
NDC. Ibuprofen
Date Reported Enter date of allergy onset or when
allergy was first reported, if available. 09-02-2001
Specific Type Enter more precise information about
the allergy, if available. NSAID
*Allergy Status Mandatory field with drop-down list
options of “current” or “past.” Current
Reaction /
Observation
Enter details about the patient’s
allergy reaction, if available. Rash, dizziness, nausea,
Severity: Low to
High
Slide the toggle back and forth to
select a number that best reflects
allergy severity, if known.
7
Intervention Enter details about the prescribed
intervention, if available. Avoid NSAIDs
Notes Enter additional notes, if appropriate.
65. Click Save. Note, the allergy information displays in the Known Allergies section.
• To close this window without saving, click Cancel or the X in the upper right
corner.
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Submit
66. Click Submit at the bottom of the screen to submit the request.
• The system displays an alert if any required information is missing. If necessary,
enter missing information and click Submit again.
Complete Prior Authorization Questionnaire
67. The Prior Authorization Questionnaire window displays.
• Do not click outside this window before completing the required fields and
clicking Submit. Clicking outside the window will close it and you will have to
start again.
68. Complete the *Provider Address, *City, *State, and *Zip Code fields.
69. Select New Therapy, Renewal or Step Therapy Exception from the *This request is
for…drop-down list
• If New Therapy or Step Therapy Exception is selected, complete the
*Administration and the *Administration Location fields.
▪ An “other” option is also available; when selected a *mandatory field
presents where further information can be entered.
• Select Yes or No from the *Has the patient tried any other medications for this
condition? drop-down list.
▪ If No, select Yes from the *attestation drop-down list and then click Submit.
▪ If Yes, enter the *patient’s medication history including type, duration, and
response in the field provided.
o Select Yes from the *attestation drop-down list and then click
Submit.
• If Renewal is selected, complete the *Date therapy initiated and the *Duration
of therapy (specific from-to-dates) fields.
• Indicate how the patient received the medication via the *How did the patient
receive the medication? drop-down list.
▪ Depending on selection, enter the *name of the patient’s *previous
insurance OR the prior auth number in the field provided.
o An “other” option is also available; when selected a *mandatory
field presents where further information can be entered.
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• Complete the *Administration and the *Administration Location fields.
▪ An “other” option is also available; when selected a *mandatory field
presents where further information can be entered.
• Select either Yes or No from the *Has the patient tried any other medications for
this condition? drop-down list.
▪ If No, select Yes from the *attestation box and then click Submit.
▪ If Yes, enter the *patient’s medication history including type, duration, and
response in the field provided.
o Select Yes from the *attestation box and then click Submit.
Add Documentation
70. To add documentation, click Add Documents. The Upload Additional Document
window displays.
• There is no limit to the number of documents that can be attached and
uploaded to an authorization request. Additionally, there is no file size limit;
larger files will take longer to upload.
• While PDF is the preferred file type, the following are accepted: DOCX, XLSX and
image formats in both color and black/white (JPEG, JPG, GIF and PNG).
71. Click Choose File to access documents on your computer.
72. Click on a file to select it, then click Open and Upload Document.
73. To add additional documents, click Add Documents again and repeat until all
documents have been added.
74. Click Close. The documents are now attached to the authorization request and are
available to Blue Shield for review.
• This screen provides another opportunity to upload documents.
75. Click Submit
Authorization Status
76. The Request Medical Prior Authorizations window displays.
• Authorization Status, Reason, and Procedure Status will be populated.
• Reference Number – the unique searchable authorization number given to each
request – will be populated.
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77. Authorization entry is now complete. Click the Create Auth for same member or
Create Auth for different member to submit another medical (i.e., inpatient, service
request, or medication) authorization. Click the X in the upper right corner to close
and exit the system.